Precipitous Delivery Masquerading as Biliary Colic in the Setting of Depo-Provera® Failure.

Precipitous delivery in the emergency department is a high-acuity, low-occurrence event that requires rapid recognition and interdepartment cooperation to prevent fetal and maternal morbidity and mortality. Prompt recognition of the peripartum state can be delayed by reported usage of long-acting contraception and concurrent distracting complaints. In this case report, a young female presented to the emergency department with epigastric abdominal pain in the setting of recent workup for biliary colic and multiple doses of long-acting, depot contraceptive agents. Early utilization of bedside ultrasound confirmed a full-term, intrauterine pregnancy as well as an impacted gallbladder stone, followed by a precipitous footling breech presentation that required an emergent cesarean section.

Contraception and diabetes.

PIP: The topic of diabetes and contraception should be better investigated. 1 survey of 300 insulin-dependent women showed that the glucose tolerance disturbance caused by OCs (oral contraceptives) is rarely serious. OCs do seem to precipitate or exacerbate cardiovascular disease in a minority of patients. Diabetic women using OCs are advised to have regular medical examinations, to use OCs for as short a period of time as possible, and to examine alternative methods of contraception. IUDs are not a suitable alternative. A high rate of IUD failure, i.e., pregnancy with the device in situ, occurs in diabetic women. It is believed that a metabolic abnormality of the diabetic endometrium may be responsible for this. Counseling of diabetic women and their husbands in the whole area of reproduction and contraception is necessary.^ieng

Impact of bodyweight/body mass index on the effectiveness of emergency contraception with levonorgestrel: a pooled-analysis of three randomized controlled trials.

OBJECTIVE: A pooled analysis of two randomized controlled trials (RCTs) suggested that increased bodyweight and body mass index (BMI) may be associated with a greater probability of pregnancy. To address this issue we investigated whether higher bodyweight and/or BMI negatively impacted the risk of pregnancy in women receiving LNG-EC (levonorgestrel - emergency contraception) after unprotected sexual intercourse in a pooled analysis of three large multinational RCTs conducted by the World Health Organization (WHO). METHODS: A pooled analysis of three double-blind, multinational RCTs conducted by the WHO to investigate the efficacy of LNG-EC in the general population. All analyses were done on the per-protocol set (PPS) which included 5812 women who received LNG-EC within 72 hours following unprotected sexual intercourse. The analysis was based on logistic regression, with pregnancy as the outcome. BMI and weight were represented in the same model. RESULTS: A total of 56 pregnancies were available for analysis in the PPS. Increasing bodyweight and BMI were not correlated with an increased risk of pregnancy in the studied population. A limitation of this study is that despite the large study population in the pooled analysis there were relatively small numbers of women in the high-BMI and high-bodyweight subgroups. CONCLUSION: LNG-EC is effective for preventing pregnancy after unprotected intercourse or contraceptive failure and no evidence was found to support the hypothesis of a loss of EC efficacy in subjects with high BMI or bodyweight. Therefore, access to LNG-EC should not be limited only to women of lower bodyweight or BMI.

[Place of persistence trouble during oral contraception and subsequent use of emergency contraception]. / Place des troubles de la persistance contraceptive dans les situations à risque de grossesse, utilisation subséquente de la contraception d'urgence.

OBJECTIVE: In order to improve the understanding of hormonal contraceptive failures, this study evaluates the persistence of oral contraception and the use of emergency contraception (EC) during persistence incidents. We made the hypothesis of the existence of a strong link between the risk of unplanned pregnancies and these two parameters. In this study, we also evaluated women's perception of EC in order to elucidate the reasons of EC insufficient use. METHODS: One survey was carried out on Internet on a representative sample of women, aged 16-45. RESULTS: In this survey, 3775 French women were interviewed (source-population). We defined a target population of 2415 fertile women who had heterosexual intercourse during the last 12 months, and a population of 760 women at risk of unintended pregnancy who had unprotected sexual intercourse during the last 12 months(risk-population). A little more than 30% of the target population, meaning 20% of the source-population (n=745) stopped their contraceptive method temporarily for an average time of two months. Almost 60% of women had a risk of unwanted pregnancy during this period without contraception, which is 59% of the risk-population. Only 20% of women among the population at risk used EC. The main reasons given for EC insufficient use were the misperception of the risk of pregnancy, the lack of knowledge about EC and its way of use. CONCLUSION: For the first time, this survey shows that 13% of women (of the source population) decide to stop temporarily their contraceptive method for an average time of two months per year. Fifty-nine percent of unplanned pregnancy situations are due to this poor contraception persistence. Although there is a need to reduce the risk of women being at risk, it seems also highly desirable to overcome the consequences of this poor persistence. Giving information about EC and a systematic prescription during contraception consultations would lead to an increased use of EC.

Comparative study on the efficacy and acceptability of two contraceptive pills administered by the vaginal route: an international multicenter clinical trial.

The efficacy and acceptability of two widely used oral contraceptive tablets, one containing 250 mg levonorgestrel and 50 micrograms ethinyl estradiol and the other containing 150 micrograms desogestrel and 30 micrograms ethinyl estradiol, administered by the vaginal route were compared in 1055 women studied over 12,630 woman-months of vaginal contraceptive pill use. This multicenter clinical trial was performed in nine countries of the developing world by the "South to South Cooperation in Reproductive Health," an organization founded by scientists from the Third World working in the area of reproductive health, and the study was developed and coordinated by one of these centers. The findings of this study confirm the efficacy of both these tablets when administered by the vaginal route. Involuntary pregnancy rates at 1 year of 2.78 for subjects in the levonorgestrel group and 4.54 for subjects the desogestrel group showed no statistically significant difference between the two groups. However, total discontinuation rates of 47.01 for subjects in the levonorgestrel group and 56.33 for subjects in the desogestrel group showed a statistically significant difference between the two groups, and discontinuation rates attributable to prolonged bleeding of 0.6 for subjects in the levonorgestrel group and 3.2 for subjects in the desogestrel group were also significantly higher in the group of subjects using the desogestrel vaginal contraceptive pill. Blood pressure remained at admission values throughout treatment. A statistically significant weight increase from admission values occurred in both groups of subjects.

PIP: Efficacy and acceptability of 2 combined oral contraceptive pills administered vaginally are summarized. This is the 1st collaborative trial published by the South to South Cooperation in Reproductive Health. 1055 women participated in 12,630 cycles, in 9 countries, from June 1988 to May 1991. The pills were commercially available tablets containing 50 mcg ethinyl estradiol and 250 mg levonorgestrel (Schering AG, Sao Paulo, Brazil), or 30 mcg ethinyl estradiol and 15 mcg desogestrel (Organon, Sao Paulo, Brazil). Subjects were aged 17-39 younger and of lower parity from Mexico and Dominican Republic and older from Egypt and China. All had at least 1 pregnancy. 675 participated for 6 months, 470 for 1 year, 364 for 18 months, and 210 for 2 years. The 1-year discontinuation rate averaged 47.01% for the levonorgestrel group and 56.33% for the desogestrel group (p = 0.0061); 2-year discontinuation rates were 48.01% and 69.36, respectively, explained in part by higher involuntary pregnancy rates and prolonged bleeding rates in the desogestrel group. The most common medical reasons for stopping contraception were unplanned pregnancy, vaginal or vulval irritation, nausea, vaginal discharge and headache. Vaginal irritation was reported by 1%, 9 in each group. There were 32 pregnancies, 14 in the levonorgestrel and 18 in the desogestrel group. 17 were in missed pill cycles and the rest were method failures, 6 in the levonorgestrel group and 9 in the desogestrel group. The Pearl index varied from 0 in Nigeria to 12.24 in Mexico, and was 2.45 for levonorgestrel vs. 3.74 for desogestrel. There was a wide variation in discontinuation rates by center: Brazil and China had few, while many women from Dominican Republic, Mexico and Zambia left the study. Bleeding problems were common complaints, more so in the desogestrel group. There were 363 women with intermenstrual bleeding (only once in 80%), 148 with spotting (only twice in 65%). Bleeding duration was significantly less in pill cycles than baseline, pressure. Women gained an average of 1 kg over 2 years, more in the desogestrel group. The pregnancy rate of 2.78 is within the range reported for levonorgestrel rings.

Contraception with intrauterine devices.

PIP: A review of the history of contraception with intrauterine devices, characteristics of present devices, and directions of current research is presented. The serious need for population control is not yet being met by today's inconvenient, ineffective, or unsafe methods. Intrauterine devices have been best for international family planning programs because they are cheap, easily installed, and provide continuous protection. There are many different models that have been and are being used, with different effectiveness and complication rates. The most commonly used today is the Lippes Loop, with a pregnancy rate of 2.8/100 years of woman use and an expulsion rate of 10.4. Most of these failures occur in the first few months of use, after which these rates are greatly reduced. The removal rate because of bleeding or pain for the Lippes device is 14.0. Other devices commonly used have pregnancy rates ranging 1.3-4.7, expulsion rates of 2.6-25.8, and removal rates of 13.5-22.1. Expulsion is directly related to the size and design of the IUD and the age and parity of t,e recipient. It is important to match the size of the device used to the individual characteristics of the patient. Research is seeking a design that will implant itself in the endometrium to resist expulsion, but not too deeply so that it is covered. Removal for bleeding and pain remains the most frequent complication of the IUD, and it partly depends on the skill of the inserting physician and how well the patient is psychologically prepared for side effects in the first months of use. Pregnancy is the most significant IUD complication. The key to an effective IUD is an understanding of its antifertility mechanism, which has thus far eluded researchers. The IUD prevents implantation of the blastocyst in the uterine wall, which may be due to a foreign-body reaction in the endometrium. IUDs with copper cause a greater reaction than plastic devices and provide hope for a very effective device; particularly the T-shaped design, which resists expulsion. The most promising new IUD is the Dalkon Shield. It has small projections that imbed in the endometrium and a broad surface for contact with the uterine wall. In preliminary experiments the pregnancy rate with this device was 1.1, the expulsion rate 2.3, and the removal rate 2.0, much lower than that with any other device yet developed. It is concluded that IUDs such as the Dalkon Shield can provide safe contraception with high effectiveness.^ieng

Spontaneous foetal losses in women using different contraceptives around the time of conception.

Spontaneous losses between the 5th and 27th weeks of pregnancy were measured in a prospective study of 32 123 women whose contraceptive history around the time of conception was known. Diaphragm use prior to conception was associated with a significant reduction in second-trimester losses, after taking into account the effects of age, parity, race, marital status, alcohol use, and previous spontaneous or induced abortions. Women who used oral contraceptives and stopped them more than one month prior to their LMP experienced a deficit of first-trimester losses but conceptions occurring immediately after stopping the pill were followed by a small but nonsignificant increase in spontaneous abortions. After oral contraceptive failures there was an increase in first-trimester losses, but no change in the incidence of second-trimester ones. IUD failures were followed by a significant two-fold increase in the risk of both first and second-trimester losses: no differences were detected between the different brands.

PIP: Spontaneous losses between the 5th and 27th weeks of pregnancy were measured in a prospective study of 32,123 women whose contraceptive history around the time of conception was known. Diaphragm use prior to conception was associated with a significant reduction in second trimester losses, after taking into consideration the effects of parity, race, marital status, alcohol use, and previous spontaneous or induced abortions. Women who used (OC) oral contraceptives and then stopped them more than 1 month prior to their last menstrual period experienced a deficit of first trimester losses but conceptions occurring immediately after stopping the pill were followed by a small but nonsignificant increase in spontaneous abortion. After OC failures, there was an increase in first trimester losses, but no change in the incidence of second trimester ones. IUD failures were followed by a significant 2-fold increase in the risk of losses during the first and second trimesters with no differences detected between the different brands.

Contraception with progestogens and progesterone during lactation.

The growth and development of breastfed infants whose mothers used the contraceptive implants Norplant containing levonorgestrel and the injectable containing norethisterone enanthate were studied. Each group comprised of 120 women who initiated the use during the 5th to 7th week postpartum and were compared with a similar number of IUD using mothers. The breastfeeding performance did not differ between groups. The infants of the three groups performed similarly as regards their physical growth and health as well as the time of acquisition of the various milestones of psychomental development. A vaginal ring releasing 10 mg of the "natural" progesterone per 24 h was tested in breastfeeding mothers. The continuous use of the ring produced a serum level of progesterone around 4 ng/ml. This was effective in augmenting lactational infertility even through the later phases of breastfeeding when such an effect starts to wane off. The use of the ring proved to be acceptable and had no ill-effect on breastfeeding or infant growth or health. Using the natural progesterone as a contraceptive adds a new measure of safety, since the amount of the steroid secreted in the mother's milk will not be effectively absorbed from the infant's gut. These studies suggest the possibility of using two new methods for breastfeeding mothers; Norplant and the progesterone vaginal contraceptive ring. These can be initiated early postpartum, whenever this is considered needed.

PIP: Weight gain and psychomotor development of breastfed infants of Egyptian mothers using Norplant, Cu T-380A IUDs, norethisterone enanthate injectables (NET-EN), Depo Provera and a levonorgestrel minipill were compared in 2 trials. First, groups of 120 women using Norplant and NET-EN were compared to a control group using IUDs, beginning 5-7 weeks postpartum. There were no differences in infant weight gain, mid-arm circumference, triceps-skin-fold thickness, or timing of motor milestones. The mean growth curve of all 3 groups were close to that of the 50th percentile for Egyptian infants. While timing of initiation of supplements was similar in the 3 groups, complete weaning occurred first in the IUD group, second in the Norplant group, and last in the NET-EN users. A second trail compared progesterone implants injected with a trocar that resulted in a blood level of 3 ng/ml for 5 months, with Population Council vaginal rings releasing 10 progesterone/24 hours, and CuT-380A IUDs. Serum progesterone in the ring users averaged 5.2 ng/ml for the 1st 2 weeks, then leveled off at about 4 ng/ml for about 2 months, falling to about 3 ng/ml for the last 3 weeks of use. Each women used 4 rings per year. Evidence of ovulation by ultrasonic vaginal probe and assay of estradiol and progesterone was apparent in 25% of vaginal ring users, compared to 55.9% of controls in the 2nd 6 months postpartum. There was 1 pregnancy in a ring users. The continuation rates were 66.6% for rings and 85.5% for IUDs. The reasons for discontinuation in vaginal ring continuation were logistical problems and unfamiliarity.

Oral contraceptive compliance during adolescence.

PIP: A review of the available literature suggests that adolescent lack of compliance with oral contraceptives (OCs) is a multifactorial problem that requires a multifactorial solution. Because of their lack of experience with contraception, higher frequency of intercourse, higher intrinsic fertility, and pattern of frequent stopping or switching of methods, adolescents experience higher OC failure rates than do adult women. Adolescents also are more likely to forget to take the pill or to discontinue due to side effects, without consulting their physician. A survey of European young women identified contraceptive protection without weight gain as the most necessary change in OCs. Adolescents must be counseled not to miss a single pill, observe the pill-free interval, take phasic formulations in the right order, and use a back-up method in case of diarrhea and vomiting or when certain medications (e.g., antibiotics and anti-epileptics) are used concurrently, and be informed of steps to take in the event of side effects and unprotected intercourse. The quality of the counseling appears to be more important to compliance than the quantity of information provided. Pharmacists should complete the counseling initiated by the physician and explain prescription use. The most significant predictor of consistent OC use is the adolescent's motivation.^ieng

A guide to interpreting contraceptive efficacy studies.

Results of trials of various birth control methods and contraceptive products may provide misleading data and engender unrealistic expectations regarding efficacy. An analysis of published efficacy-trials reveals numerous fallacies in their design, performance, and reporting. Consequently, family planning clinicians find it virtually impossible to make valid comparisons among the methods or products. This article reviews the definitions and measures that have been used to assess contraceptive efficacy, describes and illustrates some of the flaws that confound interpretation and comparison of studies, and presents a set of recommendations for future studies. A summary table providing comparative failure rates for all methods of contraception is included.

Pregnancy outcome with removal of intrauterine device.

PIP: Of 201 women who became pregnant with an IUD in situ, 120 had the device left inserted and 81 had it removed. Patients excluded from the study were those who showed evidence of threatened or incomplete abortion, those in whom the thread was not visible and the IUD not recovered during or after termination of pregnancy, and those known to have had attempts at induced abortions. The IUDs were removed only when the thread was still visible at the cervical os, when pregnancy was within the first trimester, and when the 1st attempt at pulling the thread offered no undue resistance. 12 weeks gestation was taken as the cut-off period for attempted removal since the conceptus does not fully occupy the uterine cavity until the 4th month. In the group in which the devices, mostly Lippes loops, had been left in situ there were 5 cesarean sections for obstetric indications including 1 case of placenta previa. 2 of the premature infants died during the neonatal period. Among those with the devices left in situ 48.44% aborted, compared wtih 29.62% in the removal group (p less than .02 greater than .01). When the incidence of abortion and prematurity were combined, the in situ group showed a significant increase (p less than .01). The incidence of ectopic pregnancy in this series also confirms previous reports of the relative increase (5%) among women who become pregnant with the IUD in situ. In this series of incidence was 6%. These data suggest that when continuation of pregnancy is desired, the IUD should be removed if possible.^ieng

Ectopic pregnancy following tubal sterilization surgery.

In a consecutive study of 100 women with the surgical diagnosis of ectopic pregnancy confirmed by histologic examination, 7 women were found to have had prior tubal sterilization surgery. In 3 of these cases the sterilization procedure was bilateral tubal fulguration. The diagnosis of ectopic pregnancy must be given careful consideration if patients conceive after a tubal sterilization procedure of any type.

PIP: From 6 to 10% of all maternal deaths continue to be attributed to ectopic pregnancy, usually the result of hemorrhage. The failure rate of tubal sterilization has been reported to be .25-2% for the Pomeroy procedure and .4-1.7% for bilateral tubal fulguration. The ratio of ectopic to intrauterine pregnancy is higher among pregnancies occurring after sterilizatitn failure than among the general population. The spermatozoa can get past the diminished diameter of a recanalized oviduct but the fertilized ovum cannot pass. During each year about 250 women with ectopic pregnancy are treated at the Los Angeles County-University of Southern California Medical Center. In a review of 100 consecutive cases with a confirmed diagnosis of ectopic pregnancy, 7 were found to have had tubal sterilizaiton surgery 17 months to 8 years previously. In 3 cases, bilateral tubal fulguration had been done and in 4 cases bilateral tubal ligation was performed. Ruptured extrauterine pregnancy had occurred in the distal segment of the tube in 4 and a cornual pregnancy in 1. There was 1 case of aborting tubal gestation and 1 of unruptured tubal pregnancy. In 1 case the tube containing the ectopic pregnancy had not been ligated but the round ligament was by mistake. It is thought the refulguration, as is now done, following transection of the tubes will reduce the incidence of ectopic pregnancies. The diagnosis of ectopic pregnancy should not be excluded because of a patient's history of bilateral tubal ligation or fulguration.

Female sterilization. II. A comparison of methods.

An analysis was made of 1757 female sterilization procedures performed over a 5 1/2-year period. The majority of these were accomplished by one of 8 technics: puerperal abdominal tubal ligation (TL), cesarean section plus TL, hysterotomy plus TL, interval abdominal TL, colpotomy TL, laparoscopic TL, vaginal hysterectomy, and abdominal hysterectomy. The various technics have been compared with respect to 55 variables. The procedures having the shortest hospital stay, lowest morbidity, lowest blood loss, and shortest operating time were interval laparoscopic TL, colpotomy TO, and puerperal abdominal TL. The more major procedures were attended by significantly more morbidity and longer hospitalization and should be used only when specific indications justify the increased cost and risk.

PIP: A retrospective analysis of 1757 female sterilization procedures over a 5 1/2-year period from July 1, 1965 through June 30, 1970 is presented. Almost all of the procedures were performed by either puerperal abdominal tubal ligation (TL), colpotomy TL, laparoscopic TL, interval abdominal TL, cesarean section with TL, hysterotomy with TL, vaginal hysterectomy, or abdominal hysterectomy. Operative complications were present in 90 cases, the most common of which was excessive blood loss (67 cases). Laparoscopic TL appeared to be an excellent method, given its low morbidity (8.4%), low blood loss, and short operating time and hospitalization. Colpotomy TL and puerperal abdominal TL also had favorably low incidences of morbidity and blood loss. The incidence of morbidity and length of hospitalization were considerably greater for the more major sterilization procedures. Several variables related to risk, cost, and gynecological and psychological health should be considered by the surgeon before electing a sterilization procedure.

Laparoscopic sterilization. Review of 3600 cases.

PIP: A review of 3600 cases of laparoscopy sterilization at the John Hopkins Hospital, between the years 1968-1972, is presented. Technics, complications and failure rate are discussed. The criteria for sterilization were: 1) that the patient be 21 years old (unless mentally retarded or unless the patient was a teenager whose parity was 3 or more) and 2) that she sign the hospital sterilization consent form. 3 technics were used: 1) the 2-incision technic, 1000 patients, general anethesia used, 75% outpatient; 2) 1-incision 1-burn technic, 1000 patients, local anethesia, 83% outpatient; 3) 1-incision, 3-burn technic, 1600 patients, local anethesia. Failure of the procedure to prevent pregnancy was noted in 24 patients, due to luteal pregnancies, or to surgical errors including electrocoagulation of the round ligament. The most serious complication of laparoscopy sterilization was inadvertent electrocoagulation of the gastrointestinal tract, occurring in 11 patients. Infection following laparoscopy sterilization was remarkably rare.^ieng

Failures of laparoscopy sterilization.

Female sterilization by laparoscopy has become widely accepted throughout the United States and Europe. The failure rate of this procedure is still speculative. In the course of 4200 operative sterilization, 32 failures have been identified and 31 of these have been subsequently evaluated. The most common finding was inadequate or superficial fulguration and resection. Operative errors such as round ligament fulguration were also more common than expected.

PIP: The failure rate of laparoscopic sterilization in 4200 patients aged 13-49 years is reported and suggestion are made to avoid such failures. Patients were treated at the Laparoscopy Sterilization Clinic of the Johns Hopkins Hospital over a 5-year period. 62 surgeons and about 250 visiting physicians being trained in laparoscopic technique participated. About 85% of the operations were on an outpatient basis. Indications for patients under age 18 were severe mental retardation. In the 1st 1000 cases the 2-incision method was used and a single large segment of each tube removed. For the 2nd 1000 cases a single inclision was used and only a small segment of tube removed. For the last 2200 patients a single incision was used but the proximal stump of each tube was fulgurated again. This was called the "3-burn-technique," it is the present preferred method. Of the first group 91% have been contacted and 5 failures have been recorded in a 66-month period. 3 were surgical failures and 2 were operative errors in which the round ligaments had been ligated. Among the 2nd 1000 there were 17 failures. In 12, inadequate fulguration and resection had been done, in 4, utero-overian ligament had been resected; 1 patient refused postoperative evaluation. The final group, with a 2nd fulguration of the proximal stump and wider separation of the stumps, had 10 failures in 2200 cases. There were 4 cases of unilateral incomplete section, 2 of ectopic gestation, and 3 resections of round ligaments. Of the total of 32 failures 23 occurred in the 1st 5 months after surgery. Since the adoption of the 3-burn-technique, only 6 failures have occurred when the tubes were correctly identified. In 2 of these ectopic gestation occurred. Only 2 patients in this group required laparotomy to control hemorrhage. Longer follow-up intervals will be needed before final figures are available.

Intrauterine contraceptive devices: a comparison between their use in indigent and private patients.

PIP: Use of intrauterine contraception for an aggregate 8291 months in a group of 706 private patients (mean age 27.5 years, mean number of pregnancies 2.75, 9 nulligravidas) was analyzed and compared briefly with use in a group of 623 women from a lower socioeconomic level. Considering private patients only, 195 (27.6%) had intermenstrual bleeding after IUD insertion and 27 (3.8%) experienced an increase in the amount or duration of menstrual flow. All women had cramping after insertion of the Lippes loop (or Permaspiral in 2 patients); 43 (6.1%) expelled the device. Infection developed in 9 (1.3%), and perforation of the uterus during insertion of the loop occurred in 2 patients. The pregnancy rate for all users was 2.6 pregnancies per 100 years of use. Termination of intrauterine contraception in 216 (30.6%) was because of intermenstrual bleeding (89 women), increased menstrual flow (7), cramping (19), infection (8), spontaneous ejection (22), a sterilizing operation on either spouse (8), pregnancy when IUD inserted (2), pregnancy desired (37), and other personal reasons (6). The IUD continued to be acceptable to 535 (75.8%, including those sterilized or desiring pregnancy) of 706 upper and middle class women an aggregate of 6655 months of use. Private patients compared to clinic ones had a lower incidence of irregular bleeding (195 of 706 vs. 391 of 623), but more of them discontinued intrauterine contraception because of irregular or excessive bleeding (96 or 13.6% of private patients vs. 28 or 4.5% of clinic patients). The infection rate, total expulsion rate, and final rate for discontinuation due to expulsion were lower for private vs. clinic patients (1.3% vs. 8%, 6.1% vs. 15%, and 3% vs. 5.7%, respectively). It was found that the main advantage of the IUD, constant unburdensome protection against pregnancy, was important to both groups and that couples of any social class could effectively use intrauterine contraception. Differences in use are due to lesser dependence on the IUD among upper strata women, who can use other contraceptive methods successfully.^ieng

Outpatient sterilization by laparoscopy. A report of 666 patients.

PIP: Laparoscopic sterilization was performed on 666 patients, 85% of whom were over 25 years. Private and service patients of equal racial distribution were included. Of the operations, 72% were performed on an outpatient basis. A modified Steptoe procedure was used. Complications included bleeding requiring recoagulation (2.3%), bleeding requiring laparotomy, bowel injury, trocar site burns, uterine perforations, pelvic abcess, late intra-abdominal bleeding. There were five luteal phase pregnancies and two operative failures.^ieng

Seminal vesicles as organs of sperm storage.

This study was done to determine whether or not the seminal vesicles store spermatozoa. Half of the nonhuman primates' vesicles had sperm at autopsy as did one of the men dying a traumatic death. Seminal vesicle sperm storage may be the reason for continued spermatozoa in the ejaculates of men after vasectomy.

PIP: These study results indicated that seminal vesicles sperm storage may explain the continued presence of spermatozoa in ejaculate of men after vasectomy. Examination of seminal vesicle sections of various subhuman primates revealed 11/24 specimens contained sperm. Species variation was evident in the primate results. Similarly, after regular electroejaculation all seminal vesicles of 4 sacrificed rhesus monkeys showed sperm present. 7 men, who died suddenly between the ages of 18 and 30, all had sperm in the ampullae. 1 subject had a moderate amount of sperm in the distal seminal vesicle. The remainder of the men showed no evidence of vesicular sperm. Though the frequency of vesicular sperm was lower in human than nonhuman subjects, it may nevertheless explain the occasional patient who continues to ejaculate sperm long after vasectomy and the occasional pregnancy which occurs in the absence of recanalization.

Vasectomy failure and open-ended vasectomy.

PIP: The author of this letter comments on the earlier exchange of letters on vasectomy failure. In the present author's opinion, vasectomy failures are most often caused by the inadequate creation of a barrier of fascia between the cut ends of the vas. The use of a magnifier makes it easier to spot and correct this error. The conventional electrosurgical unit is the worst cautery used due to the potential for current leakage between the wall of the vas and the fascia. The desiccating effect of cautery units using red hot wire makes this the unit of choice. At present, the open-end technique appears to be most effective, although the creation of a spermatic granuloma risks involvement of the spermatic nerve. Research is needed in terms of observations of the vas end in humans after open-end vasectomy and an explanation of the difference in spermatic granulomas between cases in which the end of the vas is sealed and those in which the testicular end of the vas is left open. It is speculated that this difference is due to the difference in time of development of these granulomas. Finally, it is recommended in cases of postoperative orchialgia that the vas be transected about 1 cm proximal to the vasectomy and be left open to reduce the pressure within the epididymis and create a low-pressure spermatic granuloma.^ieng

Tubal sterilization: focus on the U.S. experience.

OBJECTIVE: To review the frequency, effectiveness, and clinical sequelae of tubal sterilization with a focus on the U.S. experience. DESIGN: A review of U.S. health care statistics and English-language literature using a MEDLINE search, bibliographies of key references, and U.S. government publications. PATIENT(S): Women seeking tubal sterilization. INTERVENTION: Tubal sterilization. MAIN OUTCOME MEASURE(S): Effectiveness and long-term risks and benefits. RESULT(S): Half of the 700,000 annual bilateral tubal sterilizations (TS) are performed postpartum and half as ambulatory interval procedures. Eleven million U.S. women 15-44 years of age rely on TS for contraception. Failure rates vary by method with one third or more resulting in ectopic pregnancy. Reversal is most successful after use of methods that destroy the least tube. Evidence of menstrual or hormonal disturbance after TS is weak, although some studies find higher rates of hysterectomy among previously sterilized women. Decreased risk of subsequent ovarian cancer has been observed among sterilized women. CONCLUSION(S): Tubal sterilization is highly effective and safe. Failures, although uncommon, occur at higher rates than previously appreciated. Evidence for hormonal or menstrual changes due to TS is weak. Tubal sterilization is associated with decreased risk of ovarian cancer.

PIP: This paper examines the frequency, effectiveness, and clinical sequelae of tubal sterilization (TS) with a focus on the US experience. A review of US health care statistics and English-language literature, as well as bibliographies of key references and US government publications showed that half of the 700,000 annual bilateral TS are performed postpartum and half as ambulatory interval procedures. In addition, 11 million US women aged 15-44 years rely on TS for contraception. Failure rates vary by method with one-third or more resulting in ectopic pregnancy. Reversal is most successful after use of methods that destroy the least tube. Evidence of menstrual or hormonal disturbance after TS is weak, although some studies reported higher rates of hysterectomy among previously sterilized women. Decreased risk of subsequent ovarian cancer has been observed among sterilized women. In conclusion, TS is a highly effective and safe method of contraception.